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Permit #SR0083767 <br />Appendix IX <br />Underground Storage Tank <br />Overfill Prevention Equipment Inspection Report Form <br />TYPE OF ACTION Z Installation ❑ Repair ❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10180913 <br />Inspection Date <br />7/212021 <br />Facility Name <br />Ernie's General Store <br />Facility Address City ZIP Code <br />4407 E Waterloo Road Stockton 95215 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Inspection <br />Elite IV Contractors <br />Phone <br />(209) 461-6337 <br />Mailing Address <br />2535 Wigwam Drive Stockton, CA 95205 <br />Service Technician Performing Inspection <br />Benjarmin Malaspina <br />ContractorlTank Tester License Number <br />1001331 A-Hazmat <br />ICC Number <br />9519380 <br />Expiration Date <br />2/26/2022 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />OPW EVR UST 0182749 <br />511912023 <br />4, INSPECTION PROCEDURES INFORMATION <br />Inspection Procedures Used <br />Components Inspected <br />Industry Standard <br />Overfill Prevention Valve <br />5. CERTIFICATION BY SERVICE <br />TECHNICIAN CONDUCTING INSPECTION <br />1 hereby certify that the OPE was inspected in accordance with California Code of <br />Regulations, title 23, division 3, chapter 16, section 2637.2; that required supporting <br />documentation is attached; and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />4/2 <br />Date <br />7/2/2021 <br />Total # of Pages <br />2 <br />CERS = California Environmental Reporting System, ID = Identification, ICC = International Code <br />Council, OPE = Overfill Prevention Equipment <br />Page 1 of 2 <br />